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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600910
Report Date: 09/24/2024
Date Signed: 09/24/2024 01:53:45 PM

Document Has Been Signed on 09/24/2024 01:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ANYA'S HOMEFACILITY NUMBER:
415600910
ADMINISTRATOR/
DIRECTOR:
LETE, EUGENIOFACILITY TYPE:
735
ADDRESS:841 ALAMEDA DE LAS PULGASTELEPHONE:
(650) 620-9695
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY: 6CENSUS: 0DATE:
09/24/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator, Dee LeteTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On September 24, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced collateral visit at Lia Hotel located in San Carlos, CA. LPA met with Administrator, Dee Lete and explained the purpose of the visit.

This visit in in response to facility relocation due to termite issues that were reported to CCL on 9/17/2024. Facility is currently undergoing fumigation throughout the entire house till 9/26/2024.

During the visit at the hotel, LPA observed 3 hotel rooms for clients (2 on first floor and 1 on second floor) and 1 hotel room for staff (located on the first floor). There will be two clients in rooms one and two located on the first floor and one client in room three which is located on the second floor. Staff room is located in the corner on the first floor. Clients rooms were observed with clients' personal belongings, water, snacks, bathroom, towels, bed, and a kitchenette. Staff room was observed to have toiletries, hygiene items, locked medication, client files, and additional staff belongings.

According to the administrator, the clients will return to the hotel after their day program at 3pm and there will be 1 staff member in each room. No staff members will be sleeping in the clients' rooms as all staff are wake-staff. Administrator indicated they will provide breakfast to clients; cereal, fruits and eggs with milk, coffee or juice and for dinner they will have take-out.

According to administrator, the check out date from the hotel is on 9/26/2024 in the morning and clients will return back to the facility after their day program. Administrator will notify LPA when all clients have been returned back to the facility. Administrator will also provide LPA a report from the fumigators once fumigation process has been completed.

No citations are issued during the visit. Report is reviewed with Administrator, Dee Lete and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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